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| The Acute Abdomen- Part Vll: Potential Causes for Physician Assistants and Nurse Practitioners to Consider |
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by Bob Blumm, MA, PA-C, DFAAPA - October 6, 2010
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This is last in a series on this subject, and it remains incomplete; however, this was not meant to be a chapter in a book but rather to stimulate our thinking when we are approaching a patient with signs and symptoms of the acute abdomen. The list of surgical and medical problems can become quite lengthy, and for the purpose of having adequate understanding of the complete list of complaints, I would refer you to any good surgical textbook such as Lange’s Textbook of Surgery. This roadmap to understanding some of the presenting complaints can actually become a rewarding experience as the differential diagnosis continues to expand. In this final article on this subject, I’ll add another half dozen potential problems and allow you the enjoyment of following up on this intriguing subject.
Kidney Stones- I have had the opportunity to discover the pain associated with this problem first hand, and on three occasions, and I am not eagerly awaiting the next occurrence. As a surgical PA, I have been confronted with assisting on cases that have lasted 6-8 hours, which means that I have not replenished my supply of fluids and have allowed a dehydrated state. This abuse of my body and failure to completely rectify my habits was the cause of the additional attacks. The pain of renal colic falls under the category of “exquisite pain” as both me and the patients that I have treated can attest to. Many of us have compared the pain to that of a woman in labor, although many females take umbrage with this definition. From personal experience, the pain starts as dull flank pain which slowly begins to intensify. This pain then radiates to the groin, the testicle, and the labia majora, which is why it has earned the expression ”loin to groin.” Typically presenting signs are accompanying nausea and vomiting and the inability to stand still. Physical exam has demonstrated that patients can develop tachycardia which can cause reoccurrence of A-fib in patients that have previously been in this rhythm.
If your patient is a male, the genitals should always be examined and palpated to exclude testicular torsion or epididymitis. Upon performing diagnostic studies, 85% will have microscopic hematuria. The presence of Pyuria should prompt an investigation “upstream” to R/O glumereonephritis. Urine ph above 7 is associated with urate splitting organisms and struvite stones, whereas ph below 5 is associated with urate crystals. BUN/Creatine should be evaluated to ascertain renal function. As far as radiological studies, helical CT scan is now more popular than IVP. This study will also have the advantage of identifying an AAA.
Ectopic Pregnancy- Risk factors for EP include a history of PID, hx of EP, recent hx of tubal ligation and use of an IUD. The usual presentation is a late or delayed menses, abdominal or pelvic pain and vaginal bleeding. The evolution is from chronic pain to sudden epigastric pain that may be relieved temporarily when the ectopic pregnancy ruptures. Signs and symptoms of rupture are associated with hypotension and tachycardia (occasionally bradycardia due to diagrammatic irritation) and may present as syncope. Physical exam reveals vaginal bleeding, which may or may not be present on the first exam. Abdominal pain may be mild or severe, and depending on the progression, vital signs may or may not be normal. Usually tachycardia and tachypnea with associated hypotension are present in a rupture ectopic pregnancy. An abdominal mass is present 50% of the time and the uterus may be slightly enlarged- don’t assume this is a normal pregnancy. Diagnostic Lab studies are to perform a qualitative beta- HCG, type and screen to identify RH neg status and possible need for RH immune globulin or transfusion and a quantitative beta-neg determination. Ultrasound, both transvaginal and transabdominal should be performed.
Large Colon Obstruction- May be complicated due to partial or complete obstruction. Initially, patient will present with an ill-defined diffuse pain, nausea and vomiting and decreased flatus. Pain is crampy and then proceeds to constant with distension and tympani. The increased pain is associated with peristalsis. The most common causes are neoplasm, diverticulitis and sigmoid volvulus. Physical examination reveals distension and right sided fullness. Bowel sounds may be hyper sonant, normal or diminished. The abdomen is usually tympanic. Rebound is an ominous sign for peritonitis. Laboratory Studies: CBC, electrolytes, glucose and NUN levels. The WBC will be increased. Radiological studies may reveal distended loops of bowel and a CT scan has a sensitivity of 100%.
Abdominal Aortic Aneurysm- Risk factor for this surgical emergency is a family history, particularly a first degree relative. In addition, hypertension, smoking, male sex, and age over fifty are other common portions of the history. Rupture of an AAA is characterized by severe, tearing abdominal pain radiating to the mid and lower back or both. Progression is to hypotension, tachycardia, syncope, altered level of consciousness, shock and blue toes, which is a late sign indicating a poor prognosis. As far as additional physical examination it is important to know that a pulsitile mass is only present 25% of the time and to be aware that palpation does not increase the risk of rupture. The classic triad of pulsitile mass, hypotension and tachycardia is rare and considered a late finding. Diagnostic studies consist of an abdominal ultrasound which has 100% sensitivity and can be done safely at the bedside. This eliminates a situation where the AAA ruptures as the patient is being transferred to the CT scan department. If the patient is hemodynamically stable, an Abd/Pelvic CT with contrast is the initial study of choice. If suspected, a vascular surgeon should be contacted early in the presentation to ensure availability and to lower morbidity and mortality.
Mesenteric Infarction- Atherosclerosis, hypertension and intestinal angina (abdominal pain after eating) are common as part of the history. The classic picture is pain out of proportion to the exam. Pain is visceral, poorly localized, severe and sometimes refractory to narcotics. In 15-25% of the cases, pain is absent. Nausea and vomiting are frequent and diarrhea is present 50% of the time. Physical exam reveals normal findings in the face of excruciating abdominal pain. Gross or occult blood is present in the stomach or rectum in ½ of all the cases. Patients may have a low grade fever with associated tachycardia. Occasionally, A-Fibrillation may be observed and can be the cause of the infarction. Waiting for definitive signs is associated with 100% mortality. Diagnostic studies: 75% have a WBC of 15,000 or higher. Few patients will have lactic acidosis, and it is for this reason that an ABG and serum lactate levels can be helpful. Angiography is 88% sensitive, while CT is 80%. These people become very sick quickly, and the cases that I have assisted upon have had large areas of ischemic bowel requiring large bowel resections, and these patients, if they survive, will have GI problems such as short bowel syndrome.
As mentioned in the beginning of this last article of the series, there are many considerations in making a differential diagnosis and this study will enhance your basic diagnostic capabilities and increase your confidence when seeing these patients in the office, urgent care center and, particularly, in the emergency department.
Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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| Rc Davis (Carolinas) |
on 14 Oct 2010 at 3:56 pm |
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Nice review Bob.
I would caution to remind that an AAA may be ruled out by a bedside ultra sound, but a DISECTION is not... The pt would still need a CT w/ contrast. So get the US, but don't stop if it is negative, an equally disastrous process can still be occurring |
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